Individual and community-level determinants of skin-to-skin contact in Somaliland: a multilevel analysis of the 2020 demographic and health survey data.

Introduction: Neonatal mortality remains a significant public health challenge in Somaliland. Skin-to-skin contact (SSC) is an evidence-based intervention proven to improve newborn survival and maternal health outcomes. However, its implementation in low-resource settings like Somaliland is often limited. This study aimed to determine the prevalence of SSC and identify the individual and community-level factors associated with its practice between mothers and newborns in Somaliland. Method: This study utilized a cross-sectional design, analyzing secondary data from the 2020 Somaliland Health and Demographic Survey (SLHDS). A weighted sample of 2,139 mothers who had given birth in the preceding three years was included. The primary outcome was the practice of SSC. A multilevel mixed-effects logistic regression model was employed, grouping variables sequentially by geographic/healthcare, individual/child, and socioeconomic categories to account for hierarchical data structure and identify dominant determinants. Result: The prevalence of mother-to-newborn SSC in Somaliland was 23.8%. The multilevel analysis revealed that both community and individual factors significantly influenced this practice. The most dominant determinant of SSC was the place of delivery; mothers delivering at home had 88% lower odds of practicing SSC compared to those delivering in a health facility (AOR = 0.12, 95% CI: 0.09-0.16). Socioeconomically, mothers from the richest households were 75% more likely to practice SSC than those from the poorest households (AOR = 1.75, 95% CI: 1.17-2.61). Maternal healthcare decision-making capacity was a critical factor: the odds of SSC were significantly lower when the husband decided on healthcare alone (AOR = 0.42, 95% CI: 0.30-0.58) compared to when the mother made decisions independently. Compared to newborns perceived as large at birth, those perceived as small had higher odds of receiving SSC (AOR = 1.88, 95% CI: 1.05-3.37). The null model showed a high intraclass correlation coefficient (ICC = 51.7%), justifying the multilevel approach. Conclusion: The practice of SSC in Somaliland is alarmingly low, driven primarily by disparities in healthcare access, household wealth, and maternal decision-making autonomy. Future public health strategies should prioritize specific interventions such as subsidized transport to improve facility-based deliveries, mandate evidence-based SSC training for attendants, and implement targeted community campaigns engaging male leaders to empower women in healthcare decision-making.